Course Title: Undertake basic client assessment

Part B: Course Detail

Teaching Period: Term2 2009

Course Code: NURS5129C

Course Title: Undertake basic client assessment

School: 155T Vocational Health and Sciences

Campus: City Campus

Program: C4203 - Certificate IV in Nursing (Enrolled/Division 2 nursing)

Course Contact: City: Carylin Lenehan/ Bundoora: Erica Keen

Course Contact Phone: 9925 4837 / 9925 6649

Course Contact Email:

Name and Contact Details of All Other Relevant Staff

Nominal Hours: 30

Regardless of the mode of delivery, represent a guide to the relative teaching time and student effort required to successfully achieve a particular competency/module. This may include not only scheduled classes or workplace visits but also the amount of effort required to undertake, evaluate and complete all assessment requirements, including any non-classroom activities.

Pre-requisites and Co-requisites

HLTAP401A Confirm physical health status
HLTEN402A Communicate effectively in a nursing role

Course Description

This unit of competency describes the skills and knowledge required of an Enrolled/Division 2 Nurse in contributing to the development of
individualised health care plans by collection of data captured during a client’s
preliminary and ongoing health assessments. Assessment is based on a lifespan approach

National Codes, Titles, Elements and Performance Criteria

National Element Code & Title:

HLTEN403A Undertake basic client assessment


HLTEN403A/01 Collect data relating to client health
HLTEN403A/02 Undertake client assessment for admission and discharge
HLTEN403A/03 Contribute to planning nursing for clients in a health care environment
HLTEN403A/04 Prepare for client discharge
HLTEN403A/05 Work with clients across the life span

Performance Criteria:

HLTEN403A/01 Collect data relating to client health
1.1 Ensure appropriate introductions and explanations precede all nursing assessment and interventions
1.2 Measure vital signs of the client using appropriate biomedical equipment according to the acuity of care and physical characteristics of the client
1.3 Perform other clinical measurements/ assessments such as activities of daily living
1.5 Document current client health practices, issues and needs
1.6 Document and report variations from normal on a regular basis
1.7 Involve client in the process of data collection wherever possible
1.8 Undertake ongoing data collection, such as vital signs

HLTEN403A/02 Undertake client assessment for admission and discharge
2.1 Collect client-based data for admission and / or discharge planning
2.2 Contribute to nursing assessment documentation relating to physical, psychosocial and contextual client factors
2.3 Follow organisation policies and procedures relating to client participation
2.4 Undertake client admission with understanding of processes involved and key issues to be addressed
2.5 Take into account individual’s values and attitudes regarding health care and any issues the client may be experiencing and report to the registered nurse, as appropriate
2.6 Document client information, such as community resources, to assist in planning for discharge
2.7 Accurately record and report admission and discharge information
2.8 Respect cultural, spiritual and religious wishes during nursing assessment

HLTEN403A/03Contribute to planning nursing care for clients in a health care environment
3.1 Contribute to development of nursing care plans within the context of the area of health care and implement in consultation/collaboration with the registered nurse
3.2 Communicate effectively with clients, family and health team members within jurisdictional scope of practice
3.3 Develop, implement and evaluate contingency plans and care plans in consultation/collaboration with the registered nurse
3.4 Identify and implement stress management techniques for clients

HLTEN403A/04 Prepare for client discharge
4.1 Clarify client needs for community support services on discharge and identify appropriate community support services to the client
4.2 Promote client awareness and understanding through health education within the enrolled nurse scope of practice
4.3 Ensure client has all requirements for discharge:
- next GP’s appointment
- medications
- any referrals
4.4 Ensure documentation is completed as per policy and procedure

HLTEN403A/05 Work with clients across the life span
5.1 Work with an understanding of the different approaches to the concepts of growth and development
5.2 Work with an awareness of differing influences on human development, of genetics and environment
5.3 When working with clients across the life span, take into account differences in physical growth, cognitive and motor development, psychosocial development and issues associated with different stages of development

Learning Outcomes

Details of Learning Activities

Participate in formal lectures
Participate in simulations of client assessment
Perform elements of competence as designated for this learning segment to the required standard during clinical placement

Teaching Schedule

1. Preliminary Health Assessment including age & gender considerations and aspects of Holistic assessment. Describe factors influencing health related behaviour & common terms used.
2. Clinical Nursing Assessment Skin (sensory perception) Ht, Wt BMI & performance of ADLs
3. Biomedical Equipment
4. Clinical Nursing Assessment TPR & BP (Theory)
5. Clinical Nursing Assess TPR & BP (Prac)
6. Clinical Nursing Assessment Urinalysis (Theory 1.5 & Prac 1.5)
7. Concepts & Theories of growth Cogn & Motor devel of infants, toddlers & young children through to young adults
8. Nursing Records & report Writing, admissions & discharge process

Learning Resources

Prescribed Texts

Marieb, E. 2006 Essentials of anatomy and physiology 2nd Ed. Benjamin Cummings: San Fransisco
Crisp, J and Taylor, C. 2009 Potter & Perry’s Fundamentals of Nursing 3rd Ed. Elsevier: Sydney 


Chabner, DE 2003 Medical Terminology: a short course Saunders:Philadelphia
Harris, P, Nagy, S and Vardaxis, N 2006 Mosby’s Dictionary of Medicine, Nursing and Health Professions Elsevier:Sydney

Other Resources

Overview of Assessment

Assessment may include:
Observation in the workplace.
Written Assignments/projects, case study and scenario as a basis for discussion of issues and strategies to contribute to best practice.
Questioning: written or verbal

Assessment Tasks

Case study and scenario as a basis for discussion of issues and strategies to contribute to best practice
Staff and/or client feedback
Supporting statement of supervisor
Authenticated evidence of relevant work experience and/or formal/informal learning
Role play simulation
Exam/ test

Assessment Matrix

A summative examination assessing underpinning knowledge of normal ranges of assessment criteria, recording and reporting processes will be required. The test will constitute 100% of the required marks.
Observation and assessment of simulated scenarios throughout delivery.
Observation and assessment of clinical competencies will be ongoing during clinical placements.
To achieve competency assignment must be completed by due date and related clinical competencies achieved

Course Overview: Access Course Overview